A Quality Improvement Initiative to Reduce Hospitalizations for Low-risk Diabetic Ketoacidosis.

BACKGROUND AND OBJECTIVES: Children with established type 1 diabetes (T1D) who present to the emergency department (ED) with mild diabetic ketoacidosis (DKA) are often hospitalized, although outpatient management may be appropriate. Our aim was to reduce hospitalization rates for children with established T1D presenting to our ED with mild DKA who were considered low risk for progression of illness. METHODS: We conducted a quality improvement initiative between January 1, 2012, and December 31, 2018 among children and young adults ≤21 years of age with established T1D presenting to our tertiary care ED with low-risk DKA. Children transferred to our institution were excluded. DKA severity was classified as low, medium, or high risk on the basis of laboratory and clinical criteria. Our quality improvement initiative consisted of development and implementation of an evidence-based treatment guideline after review by a multidisciplinary team. Our primary outcome was hospitalization rate, and our balancing measure was 3-day ED revisits. Statistical process control methods were used to evaluate outcome changes. RESULTS: We identified 165 patients presenting with low-risk DKA. The baseline preimplementation hospitalization rate was 74% (95% confidence interval 64%-82%), and after implementation, this decreased to 55% (95% confidence interval 42%-67%) (-19%; P = .011). The postimplementation hospitalization rate revealed special cause variation. One patient in the postimplementation period returned to the ED within 3 days but did not have DKA and was not hospitalized. CONCLUSIONS: Hospitalization rates for children and young adults presenting to the ED with low-risk DKA can be safely reduced without an increase in ED revisits.

Grill-Related Injuries in Children Treated in US Emergency Departments, 1990-2009.

OBJECTIVE: The aim of the study was to describe grill-related injuries in pediatric patients seeking emergency treatment. METHODS: Data from the National Electronic Injury Surveillance System from 1990 through 2009 were investigated. Sample weights were used to calculate national estimates. United States Census Bureau data were used to calculate injury rates per 100,000 individuals. Linear regression and computation of relative risks (RRs) with 95% confidence intervals (CIs) were performed. RESULTS: An estimated 308,560 children were treated in US emergency departments for grill-related injuries during the study period, with an average of 15,428 cases per year. The rate of injuries increased by 32.3% during the study period. Males (62.8%) and children aged 11 to 18 years (55.8%) sustained the largest number of injuries. Children younger than 5 years were more likely to injure the head and neck (RR, 1.26 [95% CI, 1.21-1.33]), be injured by impact with a grill (RR, 1.97 [95% CI, 1.88-2.07]), and sustain burns (RR, 1.39 [95% CI, 1.35-1.45]) when compared with other age groups. Children aged 11 to 18 years were more likely to experience a fracture or dislocation (RR, 2.07 [95% CI, 1.58-2.72]) and more likely to sustain a grill-related injury while the grill was not in use (RR, 7.95 [95% CI, 6.25-10.12]). CONCLUSIONS: The rate of grill-related injuries among children is increasing, which underscores the need for increased prevention efforts. Prevention strategies should address measures such as lighting a grill and grill location in addition to burn prevention.

Yoga Therapy in Children with Cystic Fibrosis Decreases Immediate Anxiety and Joint Pain.

This study was designed to determine whether yoga might alleviate symptoms of pain, sleep disturbance, anxiety, and depression in children with cystic fibrosis (CF). CF is the most common genetic, life-limiting chronic disease among Caucasian populations. It primarily affects the lungs but also many other secretory organs and consequently leads to significant morbidities. Research has shown that children with CF have significantly increased depression, anxiety, and pain compared to their healthy counterparts. Subjects participated in six one-on-one sessions over a 10-week period with a certified instructor who designed each yoga practice based on a preestablished list of 30 yoga asanas. Questionnaires evaluating pain, sleep disturbance, sustained anxiety, immediate anxiety, and depression were administered. Differences between premeasures and postmeasures were evaluated using a two-sided test. Twenty subjects were assessed (12 females/8 males), median age of 11 (7-20) years. Mean immediate anxiety scores decreased (before session to after session 29 to 23.6, respectively, p < 0.001). Joint pain improved (3.25 to 3.65, p = 0.028). CFQ-R emotion subscale improved from 79.2 to 85 (p = 0.073), and the respiratory subscale improved from 66.7 to 79.2 (p = 0.076). Other results were less notable. We conclude that yoga may reduce immediate anxiety and joint pain in patients with CF.

Throw rug-related injuries treated in US EDs: are children the same as adults?

BACKGROUND: Various characteristics of floors and floor coverings are well established as injury hazards. Loose carpeting, such as rugs, is often cited as a hazard leading to injury. PURPOSE: To describe the epidemiology and patterns of rug, mat, and runner-related injuries in patients seeking emergency treatment. METHODS: Data from the National Electronic Injury Surveillance System from 1990 through 2009 were investigated. Sample weights were used to calculate national estimates. US Census Bureau data were used to calculate injury rates per 100 000 individuals. Linear regression and computation of relative risks (RRs) with 95% confidence intervals (CIs) were performed. RESULTS: An estimated 245 605 patients were treated in US emergency departments for rug-related injuries during the study period, with an average of 12 280 cases per year. Females (72.3%) and individuals older than 64 years (47.1%) sustained the largest number of injuries. Patients younger than 6 years were more likely to injure the head or neck region (RR, 3.52 [95% CI, 3.26-3.81]) compared with all other groups. Patients older than 18 years were more likely to experience a fracture or dislocation (RR, 2.52 [95% CI, 2.13-2.88]) and sustain an injury as a result of tripping or slipping on a rug (RR, 1.36 [95% CI, 1.26-1.41] compared with other age groups. Increasing age was associated with increased risk of hospitalization in this study. Patients who sustained an injury from a rubber or plastic mat/rug were significantly less likely to be admitted (RR, 0.67 [95% CI, 0.55-0.83]). Injuries occurring in kitchens or bathrooms resulted in significantly higher admission rates (RR, 1.45 [95% CI, 1.34-1.54]). CONCLUSIONS: Rug-related injuries are an important source of injury for individuals of all ages.

Does age affect analgesia provision at discharge among children with long bone fractures requiring emergency care?

BACKGROUND: Inadequate treatment of painful conditions in children is a significant and complex problem. The wide range of cognitive abilities associated with a child's age is a particular challenge for providers treating children with painful conditions. STUDY OBJECTIVE: To examine the effect of patient age on the provision of analgesic medicines at discharge in children treated emergently for a long bone fracture. METHODS: A retrospective review was performed of all patients during a 1-year period with a long bone fracture treated in two urban pediatric Emergency Departments (EDs). RESULTS: Eight hundred seventy-eight patients were identified who met our inclusion criteria. Nearly 60% of patients received a prescription for an opioid-containing medicine and 19% received a prescription for an over-the-counter analgesic medicine at ED discharge. Patients younger than 4 years old had lower pain scores, less severe fractures, and overall were significantly less likely to receive an opioid-containing prescription compared to children 4 years old or greater. In children with more severe fractures requiring reduction in the ED, no significant age-related differences were noted in opioid prescription rates. No age-related significant differences were noted for over-the-counter prescription analgesic medicines provided at discharge. CONCLUSION: Young patient age is associated with different analgesic prescription patterns in children treated in the ED for a long bone fracture.

Childhood death attributable to trauma: is there a difference between accidental and abusive fatal injuries?

BACKGROUND: Trauma is a leading cause of death among children worldwide. Detailed knowledge of the epidemiology of childhood fatal injuries is necessary for preventing injuries. OBJECTIVE: To determine clinical differences between children who were treated in an emergency department for accidental or abusive injuries. METHODS: A retrospective review of all deceased patients who were treated in two urban pediatric emergency departments between 1998 and 2010 was performed. Patients were categorized into two groups, accidental and abusive, for comparison. RESULTS: A total of 1498 patients died during the study period, with 124 deaths being attributable to injury for a rate of 9.5 injury-related deaths per year. Most fatal injuries were accidental. Children with abusive fatal injuries were younger and more likely to have been seen for an injury in a clinic or emergency department within 2 months of their death. Eighty-two percent of abusive fatal injuries had documented subdural hematomas, whereas only 7.2% of accidental fatal injuries had a subdural hematoma documented. Nearly 50% of abusive fatal injuries had retinal hemorrhages reported, although no child with an accidental fatal injury had this type of injury documented. CONCLUSION: Younger children, especially those previously seen in an emergency department or clinic for injury, are more likely to sustain an abusive fatal injury. Sentinel physical findings associated with abusive fatal injuries include subdural hematomas and retinal hemorrhages, and the presence of these findings should prompt an investigation into the circumstances of injury.

Race, ethnicity, and analgesia provision at discharge among children with long-bone fractures requiring emergency care.

BACKGROUND: Inadequate treatment of painful conditions in children is a significant and complex problem. The objective of this study was to examine the effect of race/ethnicity on the provision of analgesic medicines at discharge in children treated emergently for a long-bone fracture. METHODS: A retrospective review of all patients during a 1-year period with a long-bone fracture treated in 2 urban pediatric emergency departments was performed. RESULTS: Eight hundred seventy-eight patients who met our inclusion criteria were identified. Sixty percent of patients received a prescription for an opioid-containing medicine, and 19% received a prescription for an over-the-counter analgesic medicine at emergency department discharge. Patients identified as African American, non-Hispanic, biracial, and Hispanic/Latino had significantly lower rates of opioid analgesic prescriptions when compared with other ethnic groups. White, non-Hispanic patients had lower rates of over-the-counter analgesic medicine prescriptions provided at discharge. Patients identified as white, non-Hispanic had a higher percentage of fractures that required reduction in the emergency department when compared with other ethnic groups. CONCLUSIONS: Race/ethnicity is associated with different analgesic prescription patterns in children treated in the emergency department for a long-bone fracture.

Incidental findings on computed tomography scans in children with mild head trauma.

BACKGROUND: Computed tomography (CT) scans are frequently used in managing traumatic brain injuries in children. OBJECTIVE: To assess incidental findings in children with head trauma undergoing CT scan and to describe any associated clinical ramifications. MATERIALS AND METHODS: Retrospective review of 524 children treated in 2 emergency departments for closed head injury who received a CT scan. RESULTS: Overall, 137 (26.2%) patients had an incidental finding on CT scan. The most common incidental finding was sinus opacification with an air fluid level (115/137, 83.9%). Thirty-five interventions were reported in children with incidental findings. Children 2 years old or younger were more likely to receive a prescription for antibiotics (relative risk [RR] = 2.66, 95% confidence interval [CI] = 1.08-6.51) and be referred to a specialist (RR = 10.26, 95% CI = 3.56-29.56) than older children. CONCLUSION: Incidental findings in minor head trauma are common. Clinicians should be prepared to address these findings if clinically indicated.

Animated video vs pamphlet: comparing the success of educating parents about proper antibiotic use.

OBJECTIVE: The objective was to create an animated video to teach parents about the appropriate use of antibiotics and to compare their knowledge to parents who were provided with the American Academy of Pediatrics pamphlet. We hypothesized that the video format would result in improved comprehension and retention. METHODS: This prospective randomized, controlled trial was conducted in an urban pediatric emergency department. Parent subjects were randomly assigned to a control group, a pamphlet group, and a video group and completed a survey at 3 time points. Analysis included the nonparametric matched Friedman test, Kruskal-Wallis test, and the Mann-Whitney U test. A 2-sided P value of < .05 was required for significance, and a Bonferroni-corrected P value of < .017 was required for paired comparisons. RESULTS: Postintervention survey scores improved significantly in the pamphlet and video groups compared with baseline. The video group's follow-up scores were not significantly different from the postintervention-survey scores (P = .32). The pamphlet-group scores at follow-up were significantly lower than the postintervention-survey scores (P = .002). The control group's scores were similar at all 3 time periods. The pamphlet group had significantly better scores than the control group after the intervention (P < .001). The video-group scores exceeded the control-group scores at all 3 time periods. CONCLUSIONS: An animated video is highly effective for educating parents about the appropriate use of antibiotics in the emergency department setting and results in long-term knowledge retention. The results of this study provide a foundation to further evaluate the use of animated video in additional populations.

Learning to play the violin: motor control by freezing, not freeing degrees of freedom.

Playing a violin requires precise patterns of limb coordination that are acquired over years of practice. In the present study, the authors investigated how motion at proximal arm joints influenced the precision of bow movements in novice learners and experts. The authors evaluated the performances of 11 children (4-12 years old), 3 beginning-to-advanced level adult players, and 2 adult concert violinists, using a musical work that all had mastered as their first violin piece. The authors found that learning to play the violin was not associated with a release or freeing of joint degrees of freedom. Instead, learning was characterized by an experience-dependent suppression of sagittal shoulder motion, as documented by an observed reduction in joint angular amplitude. This reduction in the amplitude of shoulder flexion-extension correlated highly with a decrease of bow-movement variability. The remaining mechanical degrees of freedom at the elbow and shoulder showed patterns of neither suppression nor freeing. Only violinists with more than 700 practice hr achieved sagittal shoulder range of motion comparable to experts. The findings imply that restricting joint amplitude at selected joint degrees of freedom, while leaving other degrees of freedom unconstrained, constitutes an appropriate strategy for learning complex, high-precision motor patterns in children and adults. The findings also highlight that mastering even seemingly simple bowing movements constitutes a prolonged learning process.